Rural Health

September 26, 2011

Women represent over half (52%) of the 60 million people who live in rural and frontier areas in the United States. In recent years, the image of rural life as simple, healthy, and natural has been replaced with a more complex understanding in which distinct physiological stresses, physical hardships, and community patterns of rural life are also recognized. For example, age-adjusted death rates of rural women are a fourth (24%) higher than for their urban counterparts, and rural women make fewer doctor visits, are more likely to be seriously ill, and are more likely to be admitted to the hospital when they do seek medical attention. In addition, chronic physical illnesses (e.g., diabetes and arthritis), addiction, mental illness, and long-term sequelae of serious conditions associated with urban populations such as HIV and hepatitis are increasingly recognized for their burden among rural women. Rural women may not be able to overcome the additional barriers to optimal health services that exist in nonmetropolitan settings compared to urban areas, including limited access to care, fewer facilities, increased travel time, lack of specialized caregivers, and fewer patients having adequate insurance. Rural health care also poses special ethical problems surrounding health care that are related to overlapping personal and professional relationships, confidentiality, and stigma. For these reasons, the health care of women who reside in rural areas deserves special attention.

Rural women experience diverse health concerns, encompassing accidents and injuries, addictions, mental illnesses, and reproductive health. About one third of all U.S. births take place in rural areas, and rural women have their first pregnancy earlier in life and have more children than their urban counterparts. However, appropriate, affordable obstetric care is unavailable in many rural counties. Rural women with high-risk pregnancies are more likely to receive care that does not meet national practice standards and to develop complications such as pregnancy loss, preterm labor, premature birth, and poor infant outcome. The infant mortality rate is one fifth (20%) higher in rural areas than in metro areas (7.6 vs. 6.1 deaths per 1,000 live births), and sudden infant death syndrome (SIDS) rates are also much higher in rural areas (90 vs. 57 deaths per 100,000).

Addiction and mental illnesses affect the lives of rural women, indirectly and directly. Although fewer rural residents admit to consuming alcohol (44% rural vs. 54% urban residents), the prevalence of heavy and binge drinking among active drinkers is similar in rural and urban areas. Among heavy drinkers, two thirds (65%) of rural respondents described negative social consequences compared to only two fifths (40%) of urban people. In recent years, the use of illicit substances has increased in rural areas to the levels in urban communities, and rural states and counties have higher arrest rates for substance abuse violations (e.g., driving under the influence, liquor law violations, possession of illegal substances) than nonrural areas. Approximately one quarter of rural women have a diagnosable mental illness, and nearly one half will experience some significant mental health problem sometime during their lives. The consequences of coexisting addiction and mental disorders on physical and mental health can be especially severe among women in remote areas, where few resources and supports exist for them.

Rural women, like urban women, also face issues of domestic violence. Very few empirical studies of rural battered women exist, but it appears that living in rural environments may exacerbate issues contributing to domestic violence, perhaps because of social and physical isolation. In one study, twice as many rural women (25%) as urban women (12%) were likely to be involved in an ongoing violent relationship. Poverty, lack of public transportation, shortages of health care providers, lack of health insurance or underinsurance,

and decreased access to any resources may make it more difficult for rural women to escape abusive relationships. Furthermore, the closeness of rural communities may make it difficult for rural women to disclose abuse for fear of breaching their confidentiality. Geographical isolation and the increased availability of firearms and knives common in rural households also increase the potential lethality of domestic attacks upon rural women.

Accidents and trauma are a major concern for rural women. For example, farming has inherent risks for women, and as more women have participated in farming, their rate of machinery-related injuries has increased. Women and children suffer almost twice as many farm-related injuries as men, most (75%) of which are severe, permanent, or fatal. High rates of automobile accidents occur in remote areas, often secondary to alcohol intoxication, and contribute to the high rates of morbidity among rural women. Beyond a heavier burden of physical disability associated with accident and trauma, rural people are nearly twice as likely as city dwellers to die of injuries they sustain, partly due to the limited emergency services and time of travel to services.

Women and men in rural areas experience infections that are uncommon or rare in more urban locales. They are more likely to have jobs (e.g., farming) or avocations (e.g., hunting) that expose them to many disease-inducing organisms that are carried by animals and insects (e.g., anthrax, hantavirus, plague, tularemia, Lyme disease, brucella). Rural dwellers are more likely than urban people to be exposed to contaminated water and to improper sanitation systems, which increase risk for a number of illnesses (e.g., giardiasis, hepatitis A). Finally, migrant workers in rural areas present with infections acquired in their country of origin that are uncommon in the United States (e.g., malaria). Because physicians and other clinicians are typically trained in urban environments, when they come to practice in rural communities, they, at least initially, are often less familiar with many of the health risks that are more common in rural than urban areas.

Rural residents also show higher rates of a number of chronic conditions, many of which may relate to conditions specific to rural life. Greater heart disease rates were detected in rural areas beginning in the 1970s and continued into the 1980s and 1990s. A number of studies have revealed greater rates of certain kinds of cancer in rural than urban areas, particularly those associated with exposure to herbicides, pesticides, insecticides, and other carcinogenic substances. Greater respiratory disease (e.g., asthma, organic dust syndrome, chronic bronchitis, lung function changes) rates have been found among farm than nonfarm populations. Residents of rural communities also have higher rates of activity limitations due to chronic conditions, and fewer rural residents perceive their health to be excellent. Some studies have reported that arthritis and related disability are greater in rural areas, but that rural residents are more mobile than their similarly ill counterparts. Some neurologic diseases (e.g., Parkinson’s disease, Alzheimer’s disease, amyotrophic lateral sclerosis, chronic encephalopathy) associated with exposures to toxic chemicals used by farmers and miners have been found to have greater prevalence in rural than nonrural areas. Obesity and nutritional problems are also higher in rural communities with self-reported levels of obesity for rural residents (23%) being nearly one third higher than urban residents (16%), and rates of diabetes and hypertension may be higher in rural areas due to greater rates of obesity. Finally, for psychiatric illnesses, higher prevalence rates tend to be reported by numerous studies in urban compared to rural areas. However, some believe that psychiatric illness rates may actually be equivalent across geographic areas, and that the difference in regional rates merely reflects the much lower access to psychiatric services in rural areas.

A variety of these rural versus urban differences have been reported in studies that are confined to certain geographic areas of the United States. Some reports have questioned whether the rural-urban disease differences may be attributable largely to differences in education level or socioeconomic differences. Others have suggested that some rural-urban illness rates may be due in part to different reporting probabilities in different locales. Other research suggests that rural people may have some advantages in lifestyle over crowded urban dwellers. Some have suggested that rural populations may be slower to adopt prevention behaviors, suggested in part by the fact that rural areas use preventive health services less frequently. Thus, it may be that intervention strategies to reduce chronic disease may need to be tailored to fit the culture and demands of rural communities. It is clear, however, that sufficient research to examine rural versus urban health differences is lacking, and research to examine such differences as a function of gender is even more sparse.

Certain conditions may be highly stigmatized in small, interdependent communities and often require ongoing medical monitoring and lifestyle changes which

can be harder to accomplish due to constraints in rural settings. Health care resources in rural areas and their utilization are limited. For example, more than 95% of the most urbanized counties had psychiatric inpatient services, in contrast to only 13% of rural counties. Although rural areas are home to over one fifth of the population, they contain well less than 1% of the psychiatric beds. Similarly, less than one fifth (17%) of rural general hospitals provide psychiatric emergency services compared to one third (32%) of urban hospitals. Some data suggest that the attitudes and values (e.g., self-reliance, stoicism, shame) of rural women may interfere with their willingness to seek formal, needed health care. Alternatively, care seeking may be sought informally through social networks of rural women. This tendency may change in the coming decades if differences in urban and rural communities diminish, especially if rural women continue to experience the decline in social networks, which have served as a source of support and a buffer to the stresses of rural life.

Special ethical dilemmas can be encountered in rural communities, which are often derived from overlapping relationships wherein caregivers, patients, and families must operate in conflicting roles in smaller communities. Challenges in preserving patient confidentiality are greater in rural areas where people know most if not all members of the community. For example, in rural towns, the doctor, nurse, or clinic staff may attend the same church as the patient, their kids may go to the same school, they may shop at the same store, they may serve in the same community organization, and they may even be related to each other. In one study, physicians reported that more than 5% of their patients interacted with their physician in a nonmedical context, and nearly half reported that over 5% of their patients were friends or family members. Overlapping relationships have the potential to enrich the clinical experience by enmeshing the clinician in the overall activities of the community, but they also have the potential for being exploitative due to problems related to treatment boundaries. Respect for patient privacy is a fundamental element of the doctor-patient relationship, but maintaining confidentiality is especially difficult in small communities often due to this issue of overlapping relations. In fact, rural physicians, especially mental health providers, have been known to create “shadow charts” and use other adaptations in an effort to keep information confidential about a patient.

Despite the considerable stresses of rural life, rural women have strengths and resources, which are often overlooked. Rural women have a history of “hardiness”— of being resilient and self-reliant in meeting their own and their family’s needs. Networks of family members, neighbors and friends, healers, and local wise-persons have been diagnosing and treating health problems in rural communities for generations. Rural women have also used self-care and alternative healing practices, at times due to preference and at other times out of necessity. Rural women have thus adapted by being creative in solving health care problems for themselves and their rural families, who represent an important but neglected underserved population in this country.